FORM 1-A-SCC

VERIFICATION AND CERTIFICATION AGAINST NON-FORUM SHOPPING, SPLITTING A SINGLE

CAUSE OF ACTION AND MULTIPLICITY OF SUITS

I, __________________________________, of legal age, Filipino, married/single/widow/widower, and a resident

of _________________________________________________, on oath, state:
1. That I am the _____________________ in the above-entitled case have caused this
_______________________________ to be prepared; that I read and understood its contents which are true
and correct of my own personal knowledge and/or based on true records;
2. That I have not commenced any action or proceeding involving the same issue or subject matter, and
specifically the same check/s in the Supreme Court, the Court of Appeals or any other tribunal or agency,
particularly before the Office of the City Prosecutor of _______________________; that to the best of my
knowledge, no such action or proceeding is pending in the Supreme Court, the Court of Appeals or any
other tribunal or agency, and that, if I should learn thereafter that a similar action or proceeding has been
filed or is pending before these courts or tribunal or agency, I undertake to report that fact to the Court
within five (5) days therefrom.
3. That the filing of this case is not in violation of the rule against splitting a single cause of action or
multiplicity of suits.
4. That I knowingly and voluntarily waive and forego the institution of any criminal complaint for Violation
of Batas Pambansa Blg. 22 against the defendant herein based on the same check/s subject matter of this
Small Claims Complaint.

IN WITNESS WHEREOF, I have hereunto set my hand this ___________ day of _____________________,
20_____.

____________________________________________________

Affiant

SUBSCRIBED AND SWORN TO before me this _____ day of _________________.

NOTARY PUBLIC

Doc. No. _____

Page No. _____
Book No. _____
Series of 20___.